B-17-1169 - 0012 ANDOVER STREET - Building Permit 1/4-7
The Commonwealth of Massachusetts ly E
I IYOF
Board of Building Regulations and Standards r� :�= u�,i ru�
Massachusetts State Building Code,780 CMR SdMar
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or DemcNIA A 31 A 1
One-or Two-Family Dwelling
This Siretion For 0
0
ctai.Use Qnly
Build ng Permit Number: Date A plied
_.. _..
$uildiiig Official(Print Name) Sigflaiure Date
SECTION I:SI�EIDaTI+O> .4TdQ?i�
i 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
1;1 4/(6Q 0V1Pkz- Sr—
1.1a Is this an accepted street?yes L-""no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) L9 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
C� Public❑ Private❑ Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PIZkDI' l[3T1,''OWNERS '.
2.1,Owner]of Record:
Name(Print) City,State,ZIP
776-Z1 z2-
No.and Street Telephone Email Address
3 SECTION :IDSCItII'TIOI OF PROPOSED WORKz(eheck al➢that apply)
c New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ._Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Worle: 2
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item (Labor and Materials) Official Use Only
1.Building $ _ 1. Building Permit Fee:$ . Indicate how fee is determined:
2.Electrical $ 0 Standard City/Town Application Fee
❑Total Project Costa(item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Su ression Total All Fees:$
Cheek No. Check Amount: Cash Amount:
6.Total Project Cost: $� � ❑Paid in Full ❑Outstanding Balance Due:
2� 1 Z f11 LVD <
SECTION Se CONSTRUCTION SERVICE
5.1 Construction Supervisor License(CSL)
r. Lacense Number ExpiratioA,Dak
Name of M Holder
List CSL Type(see below)
No.and Street Desratption
U Unrestricted(Buildings up to 35,000 cu.ft.
� State; � Restricted 1&2 FamilyDwellin
Citylfown
M Masonry
RC Roofing Covering
WS I Window and Siding
SF Solid Fuel Burning Appliances
1 I Insulation
Telephone Email address D Demolition
5. n
stered Rome Improvement Contractor(HIC)
I A—Ell AM C Registration Number Expiration Date
HIC coiRpany44ame or HIC Registrant Name
-�c�Street Email address
�c -V- 6t72— P P7P
City/Town,State, Telephone
SECTION(se WORKERS'COMPENSATION M,URANCE AFFIDAVIT(l LG.1L c.152.g 25C(6))
Woraffid:avitwill
pensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes ..........t No...........❑
S>ECTM 7a OWNER AUTA To BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPMS IH OIt BIIMD;M PFRMU
I,as Owner of the subject property,hereby authorize Pe.
1: A- 1 &10,6
to act on my behalf,in all matters relative to work authorized by this building permit application.
dA"4-tA- 11 /2 -1-,/`7
Print Owner's Name(Electronic Signature) Date
SECTT(ON 76:OWN1EW OR AUTHORED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
_... -7
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES.
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund.under M.G.L.c. 142A.Other important information on the HIC Program can be found at
xv ww.mass. ok v/oca Information on the Construction Supervisor License can be found at.www.mass.gYov/&s
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"